Kelly D. Pagnotta

The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations.

Douglas J. Casa, PhD, ATC, FNATA, FACSM (Chair)*†; Jon Almquist, VATL, ATC*; Scott A. Anderson, ATC*; Lindsay Baker, PhD‡; Michael F. Bergeron, PhD, FACSM§; Brian Biagioli, EdD||; Barry Boden, MD¶; Joel S. Brenner, MD, MPH, FAAP#; Michael Carroll, MEd, LAT, ATC*; Bob Colgate**; Larry Cooper, MS, LAT, ATC*; Ron Courson, PT, ATC, NREMT-I, CSCS*; David Csillan, MS, LAT, ATC*; Julie K. DeMartini, MA, ATC†; Jonathan A. Drezner, MD††; Tim Erickson, CAA‡‡; Michael S. Ferrara, PhD, ATC, FNATA*; Steven J. Fleck, PhD, CSCS, FNSCA, FACSM§§; Rob Franks, DO, FAOASM||||; Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM*; William R. Holcomb, PhD, LAT, ATC, CSCS*D, FNATA, FNSCA§§; Robert A. Huggins, MEd, ATC†; Rebecca M. Lopez, PhD, ATC, CSCS†; Thom Mayer, MD, FACEP¶¶; Patrick McHenry, MA, CSCS*D, RSCC§§; Jason P. Mihalik, PhD, CAT(C), ATC##; Francis G. O’Connor, MD, MPH, FACSM††; Kelly D. Pagnotta, MA, ATC, PES†; Riana R. Pryor, MS, ATC†; John Reynolds, MS, VATL, ATC*; Rebecca L. Stearns, PhD, ATC†; Verle Valentine, MD††

Examining the influence of hydration status on physiological responses and running speed during trail running in the heat with controlled exercise intensity.

Lopez, RM, Casa, DJ, Jensen, KA, DeMartini, JK, Pagnotta, KD, Ruiz, RC, Roti, MW, Stearns, RL, Armstrong, LE, and Maresh, CM. Examining the influence of hydration status on physiological responses and running speed during trail running in the heat with controlled exercise intensity. J Strength Cond Res 25(11): 2944–2954, 2011—The purpose of this study was to determine the effects of dehydration at a controlled relative intensity on physiological responses and trail running speed. Using a randomized, controlled crossover design in a field setting, 14 male and female competitive, endurance runners aged 30 ± 10.4 years completed 2 (hydrated [HY] and dehydrated [DHY]) submaximal trail runs in a warm environment. For each trial, the subjects ran 3 laps (4 km per lap) on trails with 4-minute rests between laps. The DHY were fluid restricted 22 hours before the trial and during the run. The HY arrived euhydrated and were given water during rest breaks. The subjects ran at a moderate pace matched between trials by providing pacing feedback via heart rate (HR) throughout the second trial. Gastrointestinal temperature (TGI), HR, running time, and ratings of perceived exertion (RPE) were monitored. Percent body mass (BM) losses were significantly greater for DHY pretrial (−1.65 ± 1.34%) than for HY (−0.03 ± 1.28%; p < 0.001). Posttrial, DHY BM losses (−3.64 ± 1.33%) were higher than those for HY (−1.38 ± 1.43%; p < 0.001). A significant main effect of TGI (p = 0.009) was found with DHY having higher TGI postrun (DHY: 39.09 ± 0.45°C, HY: 38.71 ± 0.45°C; p = 0.030), 10 minutes post (DHY: 38.85 ± 0.48°C, HY: 38.46 ± 0.46°C; p = 0.009) and 30 minutes post (DHY: 38.18 ± 0.41°C, HY: 37.60 ± 0.25°C; p = 0.000). The DHY had slower run times after lap 2 (p = 0.019) and lap 3 (p = 0.025). The DHY subjects completed the 12-km run 99 seconds slower than the HY (p = 0.027) subjects did. The RPE in DHY was slightly higher than that in HY immediately postrun (p = 0.055). Controlling relative intensity in hypohydrated runners resulted in slower run times, greater perceived effort, and elevated TGI, which is clinically meaningful for athletes using HR as a gauge for exercise effort and performance.

Comparison of Two Fluid Replacement Protocols During a 20-km Trail Running Race in the Heat.

Abstract Lopez, RM, Casa, DJ, Jensen, K, Stearns, RL, DeMartini, JK, Pagnotta, KD, Roti, MW, Armstrong, LE, and Maresh, CM. Comparison of two fluid replacement protocols during a 20-km trail running race in the heat. J Strength Cond Res 30(9): 2609–2616, 2016—Proper hydration is imperative for athletes striving for peak performance and safety, however, the effectiveness of various fluid replacement strategies in the field setting is unknown. The purpose of this study was to investigate how two hydration protocols affect physiological responses and performance during a 20-km trail running race. A randomized, counter-balanced, crossover design was used in a field setting (mean ± SD: WBGT 28.3 ± 1.9° C). Well-trained male (n = 8) and female (n = 5) runners (39 ± 14 years; 175 ± 9 cm; 67.5 ± 11.1 kg; 13.4 ± 4.6% BF) completed two 20-km trail races (5 × 4-km loop) with different water hydration protocols: (a) ad libitum (AL) consumption and (b) individualized rehydration (IR). Data were analyzed using repeated measures ANOVA. Paired t-tests compared pre-race–post-race measures. Main outcome variables were race time, heart rate (HR), gastrointestinal temperature (TGI), fluid consumed, percent body mass loss (BML), and urine osmolality (Uosm). Race times between groups were similar. There was a significant condition × time interaction (p = 0.048) for HR, but TGI was similar between conditions. Subjects replaced 30 ± 14% of their water losses in AL and 64 ± 16% of their losses in IR (p < 0.001). Ad libitum trial experienced greater BML (−2.6 ± 0.5%) compared with IR (−1.3 ± 0.5%; p < 0.001). Pre-race to post-race Uosm differences existed between AL (−273 ± 146 mOsm) and IR (−145 ± 215 mOsm, p = 0.032). In IR, runners drank twice as much fluid than AL during the 20-km race, leading to > 2% BML in AL. Ad libitum drinking resulted in 1.3% greater BML over the 20-km race, which resulted in no thermoregulatory or performance differences from IR.

Athletic Directors' Barriers to Hiring Athletic Trainers in High Schools

CONTEXT In its best-practices recommendation, the Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs urged all high schools to have a certified athletic trainer (AT) on staff. Despite the recommendation, many high schools lack the medical services of an AT. OBJECTIVE To examine the barriers that athletic directors (ADs) face in hiring ATs in public high schools and in providing medical coverage for their student-athletes. DESIGN Qualitative study. SETTING Semistructured telephone interviews. PATIENTS OR OTHER PARTICIPANTS Twenty full-time public high school ADs (17 men, 3 women) from various geographical regions of the United States (6 North, 4 South, 4 Midwest, 6 West) participated. Data saturation guided the total number of participants. DATA COLLECTION AND ANALYSIS We completed telephone interviews guided by a semistructured questionnaire with all participants. Interviews were recorded and transcribed verbatim. Multiple-analyst triangulation and peer review were included as steps to establish data credibility. We analyzed the data using the principles of the general inductive approach. RESULTS We identified 3 themes. Lack of power represented the inability of an AD to hire an AT, which was perceived to be a responsibility of the superintendent and school board. Budget concerns pertained to the funding allocated to specific resources within a school, which often did not include an AT. Nonbudget concerns represented rural locations without clinics or hospitals nearby; misconceptions about the role of an AT, which led to the belief that first-aid-trained coaches are appropriate medical providers; and community support from local clinics, hospitals, and volunteers. CONCLUSIONS Many ADs would prefer to employ ATs in their schools; however, they perceive that they are bound by the hiring and budgeting decisions of superintendents and school boards. Public school systems are experiencing the consequences of national budget cuts and often do not have the freedom to hire ATs when other school staff are being laid off.

Arkansas' creation and implementation of health and safety legislation utilizing Ambrose's requirements for change.

The health and safety of young athletes has been an area of concern for parents, coaches, administrators, athletic trainers, and other health care professionals for years. Every year, young athletes pass away while playing high school sports. Figure 1 provides an overview of the deaths, broken into 5-year blocks (8). These deaths encompass all deaths, including those from cardiac pathologies, head injuries, exertional heat stroke (EHS), trauma, and more (8). More recently, this issue has become an area of concern for policy makers and legislators, as evidence continues to suggest many of these deaths could have been prevented with proper prevention, assessment, and treatment (1). Many states are working toward adopting new policies for high school athletics on topics that range from concussions to cardiac events and heat illness prevention. Even with the increase in policy development, many struggle with how to facilitate such changes. Table 1 highlights some major health and safety policy changes that the state of Arkansas (AR) recently was able to implement. This case study describes how AR developed and implemented a large high school health and safety initiative, specifically Act 1214: An act to promote the health and safety of students in public school athletic activities through the use of athletic trainers and professional development for coaches; and for other purposes (10). This specific policy development was chosen because it was one of the first successful large-scale changes and could serve as a good illustration for other states looking to implement a similar initiative. On August 11, 2010, 15-year-old Tyler Davenport collapsed at the end of a practice (6). He had experienced an EHS and was taken to Arkansas Children’s Hospital (6). Two days later, on August 13, 16-year-old Will James was competing in football practice and collapsed (6). He too experienced EHS. He too was taken to Arkansas Children’s Hospital (6). Although their stories are similar, they also are different. Tyler’s school, in rural AR, had no athletic trainer (6). His coaches provided the initial care and immediately called for an ambulance (6). Will’s school, in Little Rock, employed an athletic trainer who quickly realized he was experiencing a heat illness and began cooling him in a locker room shower (4). He was transported when the ambulance arrived (6). Tyler and Will were both in the intensive care unit at the hospital when Logan Johnson, a 13-year-old basketball player arrived (6). He was transferred from another hospital and he too had experienced an EHS on August 13, but this time, it was at basketball tryouts in a sweltering gymnasium (6). Logan initially was cared for by the school nurse, who still happened to be on site, before being transported to the hospital. During this time, there were three families of young men experiencing the same condition at Arkansas Children’s Hospital (6). The families soon became friends, assisting each other throughout the difficult time (6). Word spread throughout the state of these young men who were experiencing a condition that is not only preventable but also 100% survivable if recognized and treated quickly (2,7,9). Will James was released after spending 3 wk in the hospital (6). He experienced kidney damage and required dialysis even after leaving the hospital. Logan Johnson also survived after spending 10 days in the hospital (6). Tyler Davenport spent 62 days in the intensive care unit before he passed away (6). Although Patti James’s son, Will, survived his EHS, she was determined to prevent another family from experiencing what the James, Johnsons, and Davenports had that summer (6). Because of the media attention received regarding these cases, several organizations within the state embarked on the change process. Organizations including the AR Athletic Trainers’ Association, AR EMS Association, physicians from local hospitals, and the AR Athletic Association individually looked inward to see what improvements could be made. In addition to the organizations, INVITED COMMENTARY

Practice Beliefs of Team Physicians Regarding the Recognition and Treatment of Exertional Heat Stroke

The National Athletic Trainers’ Association and the American College of Sports Medicine each have a position statement for exertional heat illnesses that outlines proper assessment of core body temperature via rectal thermometry (Tre) and treatment via rapid cooling by cold water immersion (CWI). The purpose of this basic inductive research study was to investigate team physicians’ practice beliefs regarding the recognition and immediate treatment of EHS and the ways to increase and promote the use of best practices within the athletic training profession. Many of the participants recognized that in their role as a team physician, they were responsible for promoting best practices, which they believed were Tre and CWI. However, they did not believe it was their professional responsibility to provide educational training for either skill to athletic trainers, but rather that the 2 parties must work together to develop appropriate patient care policies. Numerous articles, anecdotal and empirical, have been published over the past decade regarding sudden death in sport. One condition in particular, exertional heat stroke (EHS), has garnered both media and research attention as many high school and collegiate football players continue to die as a result of EHS.1-3 The National Center for Catastrophic Injury Research (NCCIR) estimates that EHS is the leading cause of death during the hot and humid months of July and August and is among the top 3 leading causes of death in athletics, regardless of the time of year.1,3 The NCCIR retains records for only high school and collegiate sport deaths, so the data may be higher when other organized sporting events are considered. In addition, the past 5 years have been the deadliest for EHS, despite a positive prognosis for EHS when a proper diagnosis and treatment occur.1,3 A key component in preventing death from EHS is securing an accurate body temperature assessment because it allows for an accurate diagnosis. This diagnosis then directs proper management (immediate and aggressive cooling) and care after the illness, including return to sport.4-6 In 2002, the National Athletic Trainers’ Association (NATA) released a position statement on exertional heat illnesses,4 which outlines proper assessment and treatment methods. The document strongly recommends assessing body temperature via rectal thermometry (Tre) and rapid cooling by cold water immersion (CWI) for the assessment and treatment of EHS, respectively.4 In addition, the American College of Sports Medicine (ACSM) produced a similar document5 that corroborates the NATA’s position statement regarding the use of Tre and CWI for the diagnosis and treatment for EHS, respectively. These same recommendations are echoed in the NATA’s position statement on preventing sudden death in sport.6 The recommendations of the NATA and ACSM4-6 are well supported in the literature, with multiple studies and systematic reviews having confi rmed their use and effi cacy.3,7-12 Rectal temperature assessment not only provides the clinician with an estimate of body temperature that is imperative for diagnosis but also Dr Mazerolle, Ms Pagnotta, Dr Casa, and Dr Armstrong are from the Korey Stringer Institute, Department of Kinesiology, University of Connecticut, Storrs, Connecticut; and Ms McDowell is from the Brooks School, North Andover, Massachusetts. At the time this article was written, Ms McDowell was from The Pomfret School, Pomfret, Connecticut. Received: November 20, 2011 Accepted: May 23, 2012 Posted Online: December 12, 2012 The authors have no fi nancial or proprietary interest in the materials presented herein. Address correspondence to Stephanie Mazerolle, PhD, ATC, Korey Stringer Institute, Department of Kinesiology, University of Connecticut, 2095 Hillside Road, U-1110, Storrs, CT 06269-1110; e-mail: Stephanie.mazerolle@uconn.edu. doi:10.3928/19425864-20121212-01

Implementing Health and Safety Policy Changes at the High School Level From a Leadership Perspective

CONTEXT Although consensus statements and recommendations from professional organizations aim to reduce the incidence of injury or sudden death in sport, nothing is mandated at the high school level. This allows states the freedom to create and implement individual policies. An example of a recommended policy is heat acclimatization. Despite its efficacy in reducing sudden death related to heat stroke, very few states follow the recommended guidelines. OBJECTIVE To retroactively examine why and how 3 states were able to facilitate the successful creation and adoption of heat-acclimatization guidelines. DESIGN Qualitative study. SETTING High school athletic associations in Arkansas, Georgia, and New Jersey. PATIENTS OR OTHER PARTICIPANTS Eight men and 3 women (n = 11; 6 athletic trainers; 2 members of high school athletic associations; 2 parents; 1 physician) participated. Participant recruitment ceased when data saturation was reached. DATA COLLECTION AND ANALYSIS All phone interviews were digitally recorded and transcribed verbatim. A grounded-theory approach guided analysis and multiple analysts and peer review were used to establish credibility. RESULTS Each state had a different catalyst to change (student-athlete death, empirical data, proactivity). Recommendations from national governing bodies guided the policy creation. Once the decision to implement change was made, the states displayed 2 similarities: shared leadership and open communication between medical professionals and members of the high school athletic association helped overcome barriers. CONCLUSIONS The initiating factor that spurred the change varied, yet shared leadership and communication fundamentally allowed for successful adoption of the policy. Our participants were influenced by the recommendations from national governing bodies, which align with the institutional change theory. As more states begin to examine and improve their health and safety policies, this information could serve as a valuable resource for athletic trainers in other states and for future health and safety initiatives.